197607012-1-31-2024-31-AS-EMIR-DDET2Q-20250130132101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:22:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20240125095336

FACILITY NAME:	JBM RESIDENCE HOME, INC.		FACILITY NUMBER:	197607012
ADMINISTRATOR:	JOSEPHINE B. MIRANDA		FACILITY TYPE:	740
ADDRESS:	3205 ARIOUS WAY		TELEPHONE:	(661) 522-1968
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Josephine Miranda		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is operating beyond the terms and conditions of the Hospice Waiver.

INVESTIGATION FINDINGS:

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On 01/31/2024 at 9:41 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted a complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by staff #1 (S1) at the front door while LPA was ringing the door bell. S1 tried to enter thru the front door but it was locked. S1 went around the side of the house and opened the front door and LPA was granted access. Administrator Josephine Miranda greeted LPA and LPA explained the purpose of todays visit. Entrance interview conducted.

From 9:51 a.m. – 10:11 a.m. LPA conducted a physical plant inspection to assure the health and safety of the clients. Currently at the facility was the administrator, S1 and three (3) out of five (5) residents. Two of the residents, resident #1 (R1) and resident #6 (R6) were not at the facility. From 10:12 a.m. to 11:40 a.m. LPA reviewed six (6) resident records and obtained copies of pertinent information. From approximately 12:12 p.m. to 1:30 p.m. LPA interviewed the administrator, S1, a family member of resident #3 (R3) and residents at the facility. At approximately 2:09 p.m. LPA reviewed seven (7) staff records. (Continue to LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 31-AS-20240125095336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
	VISIT DATE: 01/31/2024

NARRATIVE

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Allegation #1: Facility is operating beyond the terms and conditions of the Hospice Waiver.
It is alleged that three residents are or had been receiving hospice care at the same time when the facility only has a hospice waiver approved for one (1) resident. LPA reviewed sign in sheets, physician's reports, and hospice folders which revealed, resident #1 (R1), resident #3 (R3) and resident #4 (R4) were under hospice care during the time they were at the facility together. LPA's Interview with administrator revealed they understand what a hospice waiver is and how to request one from Community Care Licensing Division (CCLD). Furthermore, the administrator produced a letter dated 08/19/2009 made out to Community Care Licensing Division (CCLD) requesting a hospice waiver for a resident in the facility. According to the administrator they did not receive a reply such as an approval or denial from CCLD. According to the administrator they did not attempt to reach out to their LPA or CCLD regional office to request a status update. Administrator stated to LPA they believed they had a hospice waiver approved for two (2). Administrator acknowledges R1 and R4 are on hospice for a terminal illness and R3 was on hospice for palliative care. As of todays visit facility only has one (1) resident receiving hospice care. Based on the information obtained through interviews and record review this allegation is deemed Substantiated.

Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240125095336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2024 Section Cited CCR 87632(a)	1 2 3 4 5 6 7	(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	As of todays visit facility only has one (1) resident receiving hospice care. Administrator will sign a declaration that they will ensure the facility abides by the regulation cited. Signed declaration will be sent to LPA by POC date.
	8 9 10 11 12 13 14	Based on interview and record review, Administrator did not comply with the above section by failing to obtain a hospice care waiver and accepted or retained two (2) terminally ill residents, which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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